Fillable Printable Public Service Commission Application Form - Florida
Fillable Printable Public Service Commission Application Form - Florida
Public Service Commission Application Form - Florida
FORM PSC/RAD 43 (5/08) Note: To complete this interactive form Required
Commission Rule Nos. 25-24.720, by using your computer, use the tab key to
25-24.730 navigate between data entry fields.
- 1 -
FLORIDA PUBLIC SERVICE COMMISSION
DIVISION OF REGULATORY ANALYSIS
APPLICATION FORM
for
AUTHORITY TO PROVIDE ALTERNATIVE ACCESS VENDOR SERVICE
WITHIN THE STATE OF FLORIDA
Instructions
A. This form is used as an application for an original certificate and for approval of sale,
assignment or transfer of an existing certificate. In the case of a sale, assignment or
transfer, the information provided shall be for the purchaser, assignee or transferee
(See Page 9).
B. Print or type all responses to each item requested in the application and appendices. If
an item is not applicable, please explain.
C. Use a separate sheet for each answer which will not fit the allotted space.
D. Once completed, submit the original and one copy of this form along with a non-
refundable application fee of $250.00 to:
Florida Public Service Commission
Office of Commission Clerk
2540 Shumard Oak Blvd.
Tallahassee, Florida 32399-0850
(850) 413-6770
E. A filing fee of $250.00 is required for the sale, assignment or transfer of an existing
certificate to another company (Chapter 25-24.730, F.A.C.).
F. If you have questions about completing the form, contact:
Florida Public Service Commission
Division of Regulatory Analysis
2540 Shumard Oak Blvd.
Tallahassee, Florida 32399-0850
(850) 413-6600
FORM PSC/RAD 43 (5/08) Note: To complete this interactive form Required
Commission Rule Nos. 25-24.720, by using your computer, use the tab key to
25-24.730 navigate between data entry fields.
- 2 -
1. This is an application for (check one):
Original certificate (new company).
Approval of transfer of existing certificate: Example, a non-certificated
company purchases an existing company and desires to retain the original certificate
authority rather that apply for a new certificate.
Approval of Assignment of existing Certificate: Example, a certificated
company purchases an existing company and desires to retain the existing
certificate of authority and tariff.
Approval for transfer of control: Example, a company purchases 51% of a
certificated company. The Commission must approve the new controlling entity.
2. Name of company:
3. Name under which applicant will do business (fictitious name, etc.):
4. Official mailing address:
Street/Post Office Box:
City:
State:
Zip:
5. Florida address:
Street/Post Office Box:
City:
State:
Zip:
6. Structure of organization:
Individual Corporation
Foreign Corporation Foreign Partnership
General Partnership Limited Partnership
Other,
FORM PSC/RAD 43 (5/08) Note: To complete this interactive form Required
Commission Rule Nos. 25-24.720, by using your computer, use the tab key to
25-24.730 navigate between data entry fields.
- 3 -
7. If individual, provide:
Name:
Title:
Street/Post Office Box:
City:
State:
Zip:
Telephone No.:
Fax No.:
E-Mail Address:
Website Address:
8. If incorporated in Florida,
provide proof of authority to operate in Florida. The
Florida Secretary of State corporate registration number is:
9. If foreign corporation, provide proof of authority to operate in Florida. The Florida
Secretary of State corporate registration number is:
10. If using fictitious name (d/b/a), provide proof of compliance with fictitious name
statute (Chapter 865.09, FS) to operate in Florida. The Florida Secretary of State
fictitious name registration number is:
11. If a limited liability partnership, please proof of registration to operate in Florida. The
Florida Secretary of State registration number is:
12. If a partnership, provide name, title and address of all partners and a copy of the
partnership agreement.
Name:
Title:
Street/Post Office Box:
City:
State:
Zip:
Telephone No.:
Fax No.:
E-Mail Address:
Website Address:
13. If a foreign limited partnership,
provide proof of compliance with the foreign limited
partnership statute (Chapter 620.169, FS), if applicable. The Florida registration
number is:
FORM PSC/RAD 43 (5/08) Note: To complete this interactive form Required
Commission Rule Nos. 25-24.720, by using your computer, use the tab key to
25-24.730 navigate between data entry fields.
- 4 -
14. Provide F.E.I. Number(if applicable):
15. Provide the following (if applicable):
(a) Will the name of your company appear on the bill for your services?
Yes No
(b) If not, who will bill for your services?
Name:
Title:
Street/Post Office Box:
City:
State:
Zip:
Telephone No.:
Fax No.:
E-Mail Address:
Website Address:
(c) Who will the billed party contact to ask questions about the bill?
Name:
Title:
Telephone No.:
E-Mail Address:
(d) How is this information provided?
FORM PSC/RAD 43 (5/08) Note: To complete this interactive form Required
Commission Rule Nos. 25-24.720, by using your computer, use the tab key to
25-24.730 navigate between data entry fields.
- 5 -
16. Who will serve as liaison to the Commission in regard to the following?
(a) The application:
Name:
Title:
Street name & number:
Post office box:
City:
State:
Zip:
Telephone No.:
Fax No.:
E-Mail Address:
Website Address:
(b) Official point of contact for the ongoing operations of the company:
Name:
Title:
Street name & number:
Post office box:
City:
State:
Zip:
Telephone No.:
Fax No.:
E-Mail Address:
Website Address:
(c) Complaints/Inquiries from customers:
Name:
Title:
Street/Post Office Box:
City:
State:
Zip:
Telephone No.:
Fax No.:
E-Mail Address:
Website Address:
FORM PSC/RAD 43 (5/08) Note: To complete this interactive form Required
Commission Rule Nos. 25-24.720, by using your computer, use the tab key to
25-24.730 navigate between data entry fields.
- 6 -
17. List the states in which the applicant:
(a) has operated as an Alternative Access Vendor.
(b) has applications pending to be certificated as an Alternative Access Vendor.
(c) is certificated to operate as an Alternative Access Vendor.
(d) has been denied authority to operate as an Alternative Access Vendor and the
circumstances involved.
(e) has had regulatory penalties imposed for violations of telecommunications
statutes and the circumstances involved.
(f) has been involved in civil court proceedings with an interexchange carrier, local
exchange company or other telecommunications entity, and the circumstances
involved.
FORM PSC/RAD 43 (5/08) Note: To complete this interactive form Required
Commission Rule Nos. 25-24.720, by using your computer, use the tab key to
25-24.730 navigate between data entry fields.
- 7 -
18. Indicate if any of the officers, directors, or any of the ten largest stockholders have
previously been:
(a) adjudged bankrupt, mentally incompetent (and not had his or her competency
restored), or found guilty of any felony or of any crime, or whether such actions may
result from pending proceedings. If so, provide explanation.
(b) granted or denied an alternative access vendor certificate in the State of Florida
(this includes active and canceled alternative access vendor certificates). If yes,
provide explanation and list the certificate holder and certificate number.
(c) an officer, director, partner or stockholder in any other Florida certificated
telephone company. If yes, give name of company and relationship. If no longer
associated with company, give reason why not.
FORM PSC/RAD 43 (5/08) Note: To complete this interactive form Required
Commission Rule Nos. 25-24.720, by using your computer, use the tab key to
25-24.730 navigate between data entry fields.
- 8 -
THIS PAGE MUST BE COMPLETED AND SIGNED
REGULATORY ASSESSMENT FEE: I understand that all telephone companies must pay
a regulatory assessment fee. Regardless of the gross operating revenue of a company, a
minimum annual assessment fee, as defined by the Commission, is required.
RECEIPT AND UNDERSTANDING OF RULES: I acknowledge receipt and understanding
of the Florida Public Service Commission's rules and orders relating to the provisioning of
alternative access vendor (AAV) service in Florida.
APPLICANT ACKNOWLEDGEMENT: By my signature below, I, the undersigned officer,
attest to the accuracy of the information contained in this application and attached
documents and that the applicant has the technical expertise, managerial ability, and
financial capability to provide alternative access vendor service in the State of Florida. I
have read the foregoing and declare that, to the best of my knowledge and belief, the
information is true and correct. I attest that I have the authority to sign on behalf of my
company and agree to comply, now and in the future, with all applicable Commission rules
and orders.
Further, I am aware that, pursuant to Chapter 837.06, Florida Statutes, "Whoever
knowingly makes a false statement in writing with the intent to mislead a public
servant in the performance of his official duty shall be guilty of a misdemeanor of the
second degree, punishable as provided in s. 775.082 and s. 775.083."
Company Owner or Officer
Print Name:
Title:
Telephone No.:
E-Mail Address:
Signature:_________________________________________ Date:____________
FORM PSC/RAD 43 (5/08) Note: To complete this interactive form Required
Commission Rule Nos. 25-24.720, by using your computer, use the tab key to
25-24.730 navigate between data entry fields.
- 9 -
CERTIFICATE SALE, TRANSFER,
OR
ASSIGNMENT STATEMENT
As current holder of Florida Public Service Commission Certificate Number , I have
reviewed this application and join in the petitioner's request for a
sale
transfer
assignment
of the certificate.
Company Owner or Officer
Print Name:
Title:
Street/Post Office Box:
City:
State:
Zip:
Telephone No.:
Fax No.:
E-Mail Address:
Signature:_________________________________________ Date:____________
